Provider Demographics
NPI:1326036484
Name:REYNOLDS, MARK PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PAUL
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1277
Mailing Address - Street 2:
Mailing Address - City:EAST HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59635-1277
Mailing Address - Country:US
Mailing Address - Phone:406-495-7052
Mailing Address - Fax:406-495-7052
Practice Address - Street 1:2195 E CUSTER AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-1217
Practice Address - Country:US
Practice Address - Phone:406-495-7053
Practice Address - Fax:406-495-7052
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT425OPT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT28260OtherBCBS
MT0483912Medicaid
MT410044874OtherRAILROAD MEDICARE
MT28260OtherBCBS
MT0483912Medicaid
MT0946930001Medicare NSC
MT000002967Medicare ID - Type Unspecified